Provider Demographics
NPI:1467940320
Name:PERDOMO MIRANDA, YANET
Entity Type:Individual
Prefix:
First Name:YANET
Middle Name:
Last Name:PERDOMO MIRANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8635 NW 8TH ST APT 324
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-5945
Mailing Address - Country:US
Mailing Address - Phone:786-656-5057
Mailing Address - Fax:
Practice Address - Street 1:8900 SW 24TH ST STE 207
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165
Practice Address - Country:US
Practice Address - Phone:954-842-3501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty